Status:
Ready to upload
Record number:
1821
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
This is the first case of infection due to this specific strain of Candida spp, namely, Candida stellimalicola. However, the estimated frequency of contamination of preservation fluid due to Candida spp in solid organ transplantation is approximately 1–2%
Time to detection:
Candida stellimalicola was detected in the preservation fluid by day +5.
Alerting signals, symptoms, evidence of occurrence:
In this case, there was no laboratory evidence of infection in the recipient; through post-operative day (POD) 3, C-reactive protein (CRP) remained at 10 mg/L, but in POD 5 the CRP reached >100 mg/L. Initially, the pancreas transplant recipient received antifungal prophylaxis per protocol with fluconazole. When Candida spp was detected, fluconazole was switched to caspofungin because C. stellimalicola exhibited high MIC for azoles. At no point did the authors demonstrate any infection in the recipient beyond the positive preservation fluid culture and elevated CRP.
Demonstration of imputability or root cause:
Both the peritoneal fluid obtained post-explant from the donor and the preservation fluid from the pancreas recipient yielded the same Candida spp with identical antifungal susceptibility profiles. Of note, this was a multiorgan donor, and none of the other preservation fluids tested positive for any microorganisms. C. stellimalicola was not in the Bruker Fungi Library V1.0 nor the Vitek MS IVS V2.0. Genetic sequencing revealed >99% similarity and 100% overlap with C. Stellimalicola using GenBank and CBS databases. Imputability is probable given this pattern without any culture material from the recipient - who did respond to antifungal treatment.
Imputability grade:
2 Probable
Groups audience:
References:
Reference attachment:
Suggest references:
Donor Derived Candida stellimalicola in a Clinical Specimen: Preservation Fluid Contamination During Pancreas Procurement. Dupont D et al. Mycopathologia. 2017 Jul 5
Oriol I, Sabe N, Càmara J, Berbel D, Ballesteros MA, Escudero R, Lopez-Medrano F, Linares L, Len O, Silva JT, Oliver E, Soldevila L, Pérez-Recio S, Guillem LL, Camprubí D, LLadó L, Manonelles A, González-Costello J, Domínguez MA, Fariñas MC, Lavid N, González-Rico C, Garcia-Cuello L, Arnaiz de Las Revillas F, Fortun J, Aguado JM, Jimenez-Romero C, Bodro M, Almela M, Paredes D, Moreno A, Pérez-Cameo C, Muñoz-Sanz A, Blanco-Fernández G, Cabo-González JA, García-López JL, Nuño E, Carratalà J. The Impact of Culturing the Organ Preservation Fluid on Solid Organ Transplantation: A Prospective Multicenter Cohort Study. Open Forum Infect Dis. 2019 Apr 26;6(6):ofz180. doi: 10.1093/ofid/ofz180. PMID: 31198815; PMCID: PMC6546202.
Which trial do we need? Culture of preservation fluid in abdominal organ transplant recipients. Manuel, Oriol et al. Clinical Microbiology and Infection, Volume 29, Issue 7, 832 - 834
Note:
I do not consider a positive preservation fluid culture to be, in itself, indicative of a donor-derived infection, but rather a potential risk for one. This raises an open discussion: should all recipients be treated in sucha cases, or should the decission depend on factors such as the specific microorganism isolated, the organ transplanted, the time at detection,...
Expert comments for publication:
As C. stellimalicola is an environmental yeast, and only one preservation fluid tested positive-along with the donor post-explant peritoneal fluid, one could argue that we are facing a contaminated procedure rather than true infection. Nevertheless, it underscores the importance of systematic screening of preservation fluids and the implementation of clear protocols for management to reduce the morbidity and mortality associated with fungal contamination. In certain high-risk situations, such as this case, Candida-positive preservation fluid in a pancreas transplant procedure, early antifungal therapy may improve outcomes by preventing actual transmission of infection to the recipient.
Oriol and colleagues published a study in 2019, indicating that advanced donor age was the main associated factor for having culture-positive preservation fluid for high-risk microorganisms; SOT recipients receiving preemptive antibiotic therapy in the presence of high-risk culture-positive preservation fluid had a lower incidence of infection and a lower rate of acute rejection and graft loss. A 2023 paper by Manuel and colleagues suggests that clinical studies regarding use of preservation fluid cultures for patient treatment are less than ideal, and suggests a definitive clinical study in this realm should be conducted. The issue of preservation fluid culture remains controversial.
This case report details some of the challenges associated with identifying the Candida species in this report via MALDI and molecular methods had to be utilized to speciate both the fungal elements in donor peritoneal fluid and the preservation fluid from the organ that was transplanted into the recipient.